The Physician's Role in Reducing Childhood Gun Injuries and Deaths

After reading this article and answering the review questions, the reader will be able to:

Define the scope of gun violence against children

Recognize parental misperceptions about gun safety

Identify successful strategies to reduce youth deaths due to firearms

Describe the primary care provider’s role in preventing gun violence against children

Case

You are seeing a 5-year-old boy, J.T., in your clinic for an annual well child exam. He is in kindergarten and doing well. During the visit, his mother expresses concern and shock about the shooting at Sandyhook Elementary School. She tells you that they have two hunting rifles and one handgun in their home. This has never bothered her before, but since the Sandyhook incident she is having second thoughts about the guns. She tells you, “I don’t think they are any danger to J.T., what do you think?” How will you respond to her question?

Discussion

Gun violence is a leading cause of mortality for children and adolescents in the United States. Firearms cause the death of almost 3,000 children under the age of 19 each year. This is an average of eight gun related pediatric deaths a day. The majority of these deaths are homicide (66%) or suicide (28%), but 4% of these deaths are accidental. Among high-income countries, the U.S. has the highest rates of childhood deaths related to firearms.

Figure 1: U.S. Firearm Deaths, 2009, Children Ages 0-19 years

Homicide: 66%

Suicide: 28%

Unintentional: 4%

Undetermined: 1%

Legal intervention: 1%

(Adapted from National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention Web-Based Injury Statistics Query & Reporting System Injury Mortality Reports 1999-2009.)

Among teenagers specifically, firearms are used for the vast majority of homicides (85%) and completed suicides (63%). Adolescents are at a relatively high risk of attempting suicide or committing homicide as a consequence of their tendency toward impulsive behavior. Choosing a highly lethal method, such as a firearm, results in very high fatality rates.

In addition to mortality, firearms are also a significant source of childhood morbidity. In 2010, over 15,500 children presented to emergency departments in the U.S. for treatment of gun shot injuries. Forty percent (6,236) required hospitalization to treat these injuries at an average cost of $24,353 per case. For nonfatal child gun injuries:

80% of children were shot by someone they knew or shot themselves

56% of unintentional shootings occurred at home

42% occurred while a child was playing with or handling a gun

This study and many others support that the presence of a gun in the home is a significant risk for childhood firearm injury or gun death. Guns and gun ownership are pervasive in U.S. culture.

Guns and gun ownership are pervasive in U.S. culture. Recent studies on gun ownership show that firearms are present in 38% of U.S. households. There is notable geographic variability in gun ownership across the country, with Wyoming having the highest percentage of household gun ownership (63%) and Hawaii having the lowest (9.7%). When a gun is present in the home of a child or a teen, it is stored unlocked in almost half (43%) of these homes. Easy access to unlocked guns creates a risk of serious injury or death for the pediatric population. Figure 2 depicts the gun storage practices within homes containing firearms in the U.S. in which children are present.

Figure 2. Storage Patterns of Firearms in the U.S.

Locked, unloaded, without ammunition: 39%

Unlocked, unloaded, without ammunition: 27%

Locked, unloaded, with ammunition: 14%

Unlocked, loaded: 9%

Locked, loaded: 7%

Unlocked, unloaded, with ammunition: 4%

Parents often harbor misperceptions about guns. Many parents feel that a child does not have the coordination or grip strength to fire a gun. The average handgun requires 5 pounds of grip force to depress the trigger; the average 5-year-old can generate a grip force of 10 pounds. Parents also misperceive how their children will behave around guns. They have falsely high expectations that children will not touch a gun and underestimate that children know about the presence of a gun in the home (Table 1). Studies support that participation in comprehensive firearm safety courses have no significant effect on reducing the children’s likelihood of playing with guns or engaging in shooting behaviors.6 Graduates of childhood gun safety programs do not consistently demonstrate safe behavior around guns. Most young children cannot discriminate between a toy gun and a real one. Parents underestimate the risk a gun in the home poses to their children. Pediatricians can improve safety counseling by raising parental awareness about common child behavior around guns.

65% state the child does not know about the presence of a gun in the house

100% of children correctly reported the presence of a gun in the house6

73% of children accurately identified the location of the gun in the house5

Safe storage of guns can drastically reduce the risk of firearm death or injury (Table 2). Each of the recommendations below are associated with a protective effect in reducing unintentional firearm shootings and suicide attempts among adolescents and children.4 Pediatricians need to be aware of safe storage practices and should include this information in routine anticipatory guidance counseling for families.

Table 2. Safe Gun Storage Recommendations

Store gun in a locked location or with an extrinsic lock

Store gun unloaded

Store ammunition separate from gun

Store ammunition locked

Office counseling about firearms by health care providers is an effective method of producing behavior change that will promote home safety. Parents who own guns are willing to consider or implement their physician’s advice about safe storage. In fact, when given verbal counseling on safe storage, over 60% of parents made a safe change in home gun storage practices. Counseling should not be limited to those families suspected of gun ownership because pediatricians significantly underestimate the likelihood of gun ownership by families.7Some physicians report anxiety or fear that parents will not be receptive to gun counseling. Multiple studies verify that parents are receptive to discussing firearms with pediatricians. Through office-based counseling, pediatricians can improve parental knowledge about gun safety, facilitate changes to improve home safety and reduce childhood firearm fatalities.

Despite the data suggesting counseling is effective, studies show pediatricians are not consistently discussing the risks of gun violence with families. A recent study assessing the firearm safety counseling practices of pediatricians showed that only 11% of parents report that their pediatrician discussed gun safety with them.7 Most pediatricians (75%) reported feeling comfortable discussing firearm safety with patients, but cited insufficient training on the topic (33%) or insufficient time during visits (28%) as reasons why they failed to discuss firearm safety.8 The AAP advocates that physicians acquire the knowledge and create the time to counsel parents about the dangers of allowing children and adolescents to have access to guns. As the AAP policy states:

“Pediatricians and other child health care professionals are urged to counsel parents about the dangers of allowing children and adolescents to have access to guns inside and outside the home. The AAP recommends that pediatricians incorporate questions about the presence and availability of firearms into their patient history taking and urge parents who possess guns to prevent access to these guns by children.”1

In addition to counseling by health care providers, legislation is another effective strategy in reducing youth deaths due to firearms. Currently 18 states, including Wisconsin, have firearm safe storage laws. Child access prevention (CAP) laws hold a gun owner criminally liable if someone is injured from a child’s unsupervised access to his/her gun. Application of these laws result in a consistent decrease in unintentional youth firearm deaths and suicides.10 There are no federal CAP laws; however, twenty-eight states, including Wisconsin, have such laws. Advocating for increased state and federal gun safety laws and consistent enforcement of existing laws are additional effective ways for pediatricians to reduce childhood gun deaths.

The American Academy of Pediatrics’ policy statement on pediatric firearm injuries discusses the role of the pediatrician in preventing firearm injuries in more detail.1 The role of the pediatrician is summarized as follows:

Pediatricians and other child health care professionals are urged to counsel parents about the dangers of allowing children and adolescents to have access to guns.

Pediatricians should incorporate questions about the presence and availability of firearms into their patient history taking and urge parents who possess guns to prevent access to these guns by children.

Health care professionals should counsel the parents of all adolescents to remove guns from the home or restrict access to them.

Pediatricians should continue to advocate for the strongest possible legislative and regulatory approaches to prevent firearm injuries and deaths.